Neutropenic Enterocolitis Treatment & Management

  • Author: Keith Sultan, MD; Chief Editor: Julian Katz, MD   more...
 
Updated: Aug 11, 2011
 

Medical Care

No published randomized control trials comparing conservative medical therapy with surgical intervention in neutropenic enterocolitis (typhlitis) exist; however, advocates for both types of therapy exist. The outcome appears to reflect the state of the underlying disease and other comorbidities at the time of clinical presentation rather than the treatment modality. Therefore, a uniform management strategy for neutropenic enterocolitis (typhlitis) cannot be recommended. Individualize the approach to each patient. Early recognition of neutropenic enterocolitis (typhlitis) in a patient who is neutropenic is paramount to a good outcome.

  • Conservative management includes the following:
    • Bowel rest and nasogastric suction
    • Close monitoring of patients using serial abdominal examinations in an intensive care setting
    • Intravenous fluids, blood, and platelet transfusions as necessary
    • Parenteral broad-spectrum antibiotics: Antibiotics should include agents covering enteric gram-negative and anaerobic organisms, including Clostridium species. Metronidazole may also be considered if pseudomembranous colitis cannot immediately be excluded.
    • Cultures: Obtain blood cultures for fungus, and consider early use of antifungal agents if the disease does not respond to antibiotics.[27]
    • Avoidance of certain medications: Anticholinergic agents, antidiarrheal drugs, and narcotics may worsen the condition or further confuse the clinical picture of neutropenic enterocolitis (typhlitis).
Next

Surgical Care

  • Immediate surgery has been proposed by Shamberger et al in patients with neutropenic enterocolitis (typhlitis) and the following indications[12] :
    • Free intra-abdominal perforation
    • Clinical deterioration during conservative medical therapy
    • Differentiation from other acute abdominal conditions for which surgery is indicated
    • Unrelenting intra-abdominal sepsis or abscess formation
    • Continued hemorrhage with a platelet count and coagulation parameters within the reference range
  • Tailor the surgical procedure to the operative findings.
  • Choice of surgical procedures includes the following:
    • Cecostomy and drainage
    • A 2-stage right hemicolectomy or total abdominal colectomy, with or without a primary anastomosis
    • Defunctioning of the colon with a loop ileostomy
  • Normal-appearing serosal surfaces may conceal mucosal breakdown and necrosis. Therefore, resection should be extensive to assure removal of the diseased bowel.
  • Consider elective right hemicolectomy in patients who have required repeated courses of chemotherapy and who have responded to initial conservative medical therapy. Recurrent episodes of neutropenic enterocolitis (typhlitis) have been reported in such patients.
Previous
Next

Consultations

Joint management between medical and surgical teams is extremely important for a good outcome in patients with neutropenic enterocolitis (typhlitis).

Previous
Next

Diet

Because the patient is fasting and on bowel rest, consider parenteral nutrition.

Previous
Next

Activity

Patients with neutropenic enterocolitis (typhlitis) are usually extremely ill and in the intensive care setting on complete bed rest.

Previous
Proceed to Medication
 
 
Contributor Information and Disclosures
Author

Keith Sultan, MD  Faculty Practice, Division of Gastroenterology, Hepatology and Nutrition, North Shore University Hospital

Keith Sultan, MD is a member of the following medical societies: American College of Gastroenterology and American Gastroenterological Association

Disclosure: Nothing to disclose.

Coauthor(s)

Rajeev Vasudeva, MD, FACG  Clinical Professor of Medicine, Consultants in Gastroenterology, University of South Carolina School of Medicine

Rajeev Vasudeva, MD, FACG is a member of the following medical societies: American College of Gastroenterology, American Gastroenterological Association, American Society for Gastrointestinal Endoscopy, Columbia Medical Society, South Carolina Gastroenterology Association, and South Carolina Medical Association

Disclosure: Pricara Honoraria Speaking and teaching; UCB Consulting fee Consulting

Specialty Editor Board

Robert J Fingerote, MD, MSc, FRCPC  Consultant, Clinical Evaluation Division, Biologic and Gene Therapies, Directorate Health Canada; Consulting Staff, Department of Medicine, Division of Gastroenterology, York Central Hospital, Ontario

Robert J Fingerote, MD, MSc, FRCPC is a member of the following medical societies: American Association for the Study of Liver Diseases, American Gastroenterological Association, Canadian Medical Association, Ontario Medical Association, and Royal College of Physicians and Surgeons of Canada

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD  Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

Douglas M Heuman, MD, FACP, FACG, AGAF  Chief of GI, Hepatology, and Nutrition at North Shore University Hospital/Long Island Jewish Medical Center; Professor, Department of Medicine, Hofstra North Shore-LIJ School of Medicine

Douglas M Heuman, MD, FACP, FACG, AGAF is a member of the following medical societies: American Association for the Study of Liver Diseases, American College of Physicians, and American Gastroenterological Association

Disclosure: Novartis Grant/research funds Other; Bayer Grant/research funds Other; Otsuka Grant/research funds None; Bristol Myers Squibb Grant/research funds Other; Scynexis None None; Salix Grant/research funds Other; MannKind Other

Alex J Mechaber, MD, FACP  Senior Associate Dean for Undergraduate Medical Education, Associate Professor of Medicine, University of Miami Miller School of Medicine

Alex J Mechaber, MD, FACP is a member of the following medical societies: Alpha Omega Alpha, American College of Physicians-American Society of Internal Medicine, and Society of General Internal Medicine

Disclosure: Nothing to disclose.

Chief Editor

Julian Katz, MD  Clinical Professor of Medicine, Drexel University College of Medicine

Julian Katz, MD is a member of the following medical societies: American College of Gastroenterology, American College of Physicians, American Gastroenterological Association, American Geriatrics Society, American Medical Association, American Society for Gastrointestinal Endoscopy, American Society of Law, Medicine & Ethics, American Trauma Society, Association of American Medical Colleges, and Physicians for Social Responsibility

Disclosure: Nothing to disclose.

References

  1. Keidan RD, Fanning J, Gatenby RA, Weese JL. Recurrent typhlitis. A disease resulting from aggressive chemotherapy. Dis Colon Rectum. Mar 1989;32(3):206-9. [Medline].

  2. Wade DS, Nava HR, Douglass HO Jr. Neutropenic enterocolitis. Clinical diagnosis and treatment. Cancer. Jan 1 1992;69(1):17-23. [Medline].

  3. Davila AD, Willenbucher RF. Neutropenic typhlitis. In: Feldman M, Sleisenger MH, eds. Sleisenger and Fordtran's Gastrointestinal and Liver Disease: Pathophysiology, Diagnosis, Management. 6th ed. Philadelphia, Pa: Saunders; 1998:1998-2000.

  4. Gorbach SL. Neutropenic enterocolitis. Clin Infect Dis. Oct 1998;27(4):700-1. [Medline].

  5. Urbach DR, Rotstein OD. Typhlitis. Can J Surg. Dec 1999;42(6):415-9. [Medline].

  6. Gorschluter M, Mey U, Strehl J, et al. Neutropenic enterocolitis in adults: systematic analysis of evidence quality. Eur J Haematol. Jul 2005;75(1):1-13. [Medline].

  7. Davila ML. Neutropenic enterocolitis. Curr Opin Gastroenterol. Jan 2006;22(1):44-7. [Medline].

  8. Ullery BW, Pieracci FM, Rodney JR, Barie PS. Neutropenic enterocolitis. Surg Infect (Larchmt). Jun 2009;10(3):307-14. [Medline].

  9. Wagner ML, Rosenberg HS, Fernbach DJ, Singleton EB. Typhlitis: a complication of leukemia in childhood. Am J Roentgenol Radium Ther Nucl Med. Jun 1970;109(2):341-50. [Medline].

  10. Gorschluter M, Mey U, Strehl J, et al. Invasive fungal infections in neutropenic enterocolitis: a systematic analysis of pathogens, incidence, treatment and mortality in adult patients. BMC Infect Dis. Feb 26 2006;6:35. [Medline]. [Full Text].

  11. Katz JA, Wagner ML, Gresik MV, Mahoney DH Jr, Fernbach DJ. Typhlitis. An 18-year experience and postmortem review. Cancer. Feb 15 1990;65(4):1041-7. [Medline].

  12. Shamberger RC, Weinstein HJ, Delorey MJ, Levey RH. The medical and surgical management of typhlitis in children with acute nonlymphocytic (myelogenous) leukemia. Cancer. Feb 1 1986;57(3):603-9. [Medline].

  13. Fike FB, Mortellaro V, Juang D, St Peter SD, Andrews WS, Snyder CL. Neutropenic Colitis in Children. J Surg Res. Feb 21 2011;[Medline].

  14. Jain Y, Arya LS, Kataria R. Neutropenic enterocolitis in children with acute lymphoblastic leukemia. Pediatr Hematol Oncol. Jan-Feb 2000;17(1):99-103. [Medline].

  15. Buyukasik Y, Ozcebe OI, Haznedaroglu IC, et al. Neutropenic enterocolitis in adult leukemias. Int J Hematol. Jul 1997;66(1):47-55. [Medline].

  16. Aksoy DY, Tanriover MD, Uzun O, et al. Diarrhea in neutropenic patients: a prospective cohort study with emphasis on neutropenic enterocolitis. Ann Oncol. Jan 2007;18(1):183-9. [Medline].

  17. El-Matary W, Soleimani M, Spady D, Belletrutti M. Typhlitis in children with malignancy: a single center experience. J Pediatr Hematol Oncol. Apr 2011;33(3):e98-100. [Medline].

  18. Marie I, Robaday S, Kerleau JM, Jardin F, Levesque H. Typhlitis as a complication of alemtuzumab therapy. Haematologica. May 2007;92(5):e62-3. [Medline].

  19. Kasturi KS, Mummadi RR, Sood GK. Neutropenic enterocolitis: An unusual complication of HCV combination therapy with PEG-IFN and ribavirin. Eur J Intern Med. Jul 2008;19(5):372-3. [Medline].

  20. Kim JH, Jang JW, You CR, You SY, Jung MK, Jung JH. Fatal Neutropenic Enterocolitis during Pegylated Interferon and Ribavirin Combination Therapy for Chronic Hepatitis C Virus Infection. Gut Liver. Sep 2009;3(3):218-21. [Medline].

  21. Rizzatti M, Brandalise SR, de Azevedo AC, Pinheiro VR, Aguiar Sdos S. Neutropenic enterocolitis in children and young adults with cancer: prognostic value of clinical and image findings. Pediatr Hematol Oncol. Sep 2010;27(6):462-70. [Medline].

  22. Dietrich CF, Hermann S, Klein S, Braden B. Sonographic signs of neutropenic enterocolitis. World J Gastroenterol. Mar 7 2006;12(9):1397-402. [Medline].

  23. Cartoni C, Dragoni F, Micozzi A, et al. Neutropenic enterocolitis in patients with acute leukemia: prognostic significance of bowel wall thickening detected by ultrasonography. J Clin Oncol. Feb 1 2001;19(3):756-61. [Medline].

  24. McCarville MB, Adelman CS, Li C, et al. Typhlitis in childhood cancer. Cancer. Jul 15 2005;104(2):380-7. [Medline]. [Full Text].

  25. Kirkpatrick ID, Greenberg HM. Gastrointestinal complications in the neutropenic patient: characterization and differentiation with abdominal CT. Radiology. Mar 2003;226(3):668-74. [Medline]. [Full Text].

  26. Horton KM, Corl FM, Fishman EK. CT evaluation of the colon: inflammatory disease. Radiographics. Mar-Apr 2000;20(2):399-418. [Medline]. [Full Text].

  27. Cardona Zorrilla AF, Reveiz Herault L, Casasbuenas A, Aponte DM, Ramos PL. Systematic review of case reports concerning adults suffering from neutropenic enterocolitis. Clin Transl Oncol. Jan 2006;8(1):31-8. [Medline].

  28. Cardona Zorrilla AF, Reveiz Herault L, Casasbuenas A, Aponte DM, Ramos PL. Systematic review of case reports concerning adults suffering from neutropenic enterocolitis. Clin Transl Oncol. Jan 2006;8(1):31-8. [Medline].

  29. Gafter-Gvili A, Fraser A, Paul M, Leibovici L. Meta-analysis: antibiotic prophylaxis reduces mortality in neutropenic patients. Ann Intern Med. Jun 21 2005;142(12 pt 1):979-95. [Medline].

  30. Kuderer NM, Dale DC, Crawford J, Lyman GH. Impact of primary prophylaxis with granulocyte colony-stimulating factor on febrile neutropenia and mortality in adult cancer patients receiving chemotherapy: a systematic review. J Clin Oncol. Jul 20 2007;25(21):3158-67. [Medline].

  31. Mullassery D, Bader A, Battersby AJ, et al. Diagnosis, incidence, and outcomes of suspected typhlitis in oncology patients--experience in a tertiary pediatric surgical center in the United Kingdom. J Pediatr Surg. Feb 2009;44(2):381-5. [Medline].

  32. Alt B, Glass NR, Sollinger H. Neutropenic enterocolitis in adults. Review of the literature and assessment of surgical intervention. Am J Surg. Mar 1985;149(3):405-8. [Medline].

  33. Avigan D, Richardson P, Elias A, et al. Neutropenic enterocolitis as a complication of high dose chemotherapy with stem cell rescue in patients with solid tumors: a case series with a review of the literature. Cancer. Aug 1 1998;83(3):409-14. [Medline]. [Full Text].

  34. Badgwell BD, Cormier JN, Wray CJ, et al. Challenges in surgical management of abdominal pain in the neutropenic cancer patient. Ann Surg. Jul 2008;248(1):104-9. [Medline].

  35. Crosby WH, Haubrich WS. The death of Walter Reed. JAMA. Sep 17 1982;248(11):1342-5. [Medline].

  36. Cunningham SC, Fakhry K, Bass BL, Napolitano LM. Neutropenic enterocolitis in adults: case series and review of the literature. Dig Dis Sci. Feb 2005;50(2):215-20. [Medline].

  37. Ettinghausen SE. Collagenous colitis, eosinophilic colitis, and neutropenic colitis. Surg Clin North Am. Oct 1993;73(5):993-1016. [Medline].

  38. Gomez L, Martino R, Rolston KV. Neutropenic enterocolitis: spectrum of the disease and comparison of definite and possible cases. Clin Infect Dis. Oct 1998;27(4):695-9. [Medline].

  39. Hanada T, Ono I, Hirano C, Kurosaki Y. Successful treatment of neutropenic enterocolitis with recombinant granulocyte colony stimulating factor in a child with acute lymphocytic leukaemia. Eur J Pediatr. Aug 1990;149(11):811-2. [Medline].

  40. Hoelzer D. Hematopoietic growth factors--not whether, but when and where. N Engl J Med. Jun 19 1997;336(25):1822-4. [Medline].

  41. Kulaylat M, Doerr R, Ambrus J. A case presentation and review of neutropenic enterocolitis. J Med. 1997;28(1-2):1-19. [Medline].

  42. Lev R, Sweeney KG. Neutropenic enterocolitis. Two unusual cases with review of the literature. Arch Pathol Lab Med. May 1993;117(5):524-7. [Medline].

  43. Mulholland MW, Delaney JP. Neutropenic colitis and aplastic anemia: a new association. Ann Surg. Jan 1983;197(1):84-90. [Medline]. [Full Text].

  44. Nagler A, Pavel L, Naparstek E, Muggia-Sullam M, Slavin S. Typhlitis occurring in autologous bone marrow transplantation. Bone Marrow Transplant. Jan 1992;9(1):63-4. [Medline].

  45. Or R, Mehta J, Nagler A, Craciun I. Neutropenic enterocolitis associated with autologous bone marrow transplantation. Bone Marrow Transplant. May 1992;9(5):383-5. [Medline].

  46. Park YB, Lee JW, Cho BS, et al. Incidence and etiology of overt gastrointestinal bleeding in adult patients with aplastic anemia. Dig Dis Sci. Jan 23 2009;epub ahead of print. [Medline].

  47. Shaked A, Shinar E, Freund H. Neutropenic typhlitis. A plea for conservatism. Dis Colon Rectum. May 1983;26(5):351-2. [Medline].

  48. Sloas MM, Flynn PM, Kaste SC, Patrick CC. Typhlitis in children with cancer: a 30-year experience. Clin Infect Dis. Sep 1993;17(3):484-90. [Medline].

  49. Spencer SP, Power N, Reznek RH. Multidetector computed tomography of the acute abdomen in the immunocompromised host: a pictorial review. Curr Probl Diagn Radiol. Jul-Aug 2009;38(4):145-55. [Medline].

  50. Tiseo M, Gelsomino F, Bartolotti M, Barili MP, Ardizzoni A. Typhlitis during second-line chemotherapy with pemetrexed in non-small cell lung cancer (NSCLC): A case report. Lung Cancer. Aug 2009;65(2):251-3. [Medline].

  51. Weinberger M, Hollingsworth H, Feuerstein IM, Young NS, Pizzo PA. Successful surgical management of neutropenic enterocolitis in two patients with severe aplastic anemia. Case reports and review of the literature. Arch Intern Med. Jan 11 1993;153(1):107-13. [Medline].

 
Previous
Next
 
Ulcerative oral mucositis lesion on the lateral and ventral surfaces of the tongue.
Colonic pseudomembranes of pseudomembranous colitis. Photographs courtesy of Eric M. Osgard, MD.
Frontal abdominal radiograph in a patient with proved pseudomembranous colitis. Note the nodular haustral thickening, most pronounced in the transverse colon.
Perforated appendicitis with abscess; computed tomography scan. Note the appendicolith (arrow) and air within the abscess. The terminal ileum lies anterior to the appendiceal abscess, and inflammatory change is noted in its wall, which appears thickened (open arrow).
Plain abdominal radiograph in a 44-year-old man known to have long history of ulcerative colitis. The patient presented with an acute exacerbation of symptoms. Image shows thumbprinting in the region of the splenic flexure of the colon.
Typhlitis. Marked asymmetric cecal wall thickening (arrow) in a 64-year-old patient whose status is postchemotherapeutic for lymphoma.
Typhlitis. Marked circumferential cecal and ascending colon wall thickening (large arrows) with mild pericolonic inflammatory stranding (small arrows).
 
 
 
All material on this website is protected by copyright, Copyright © 1994-2012 by WebMD LLC.
This website also contains material copyrighted by 3rd parties.

DISCLAIMER: The content of this Website is not influenced by sponsors. The site is designed primarily for use by qualified physicians and other medical professionals. The information contained herein should NOT be used as a substitute for the advice of an appropriately qualified and licensed physician or other health care provider. The information provided here is for educational and informational purposes only. In no way should it be considered as offering medical advice. Please check with a physician if you suspect you are ill.